Urology Coding Alert

Don't count on extra pay for the nerve block, however.

When your urologist performs a circumcision, accurate CPT Coding won't get you paid if you can't prove medical necessity with the proper ICD-9 Codes -- and the diagnosis challenge is not the only hurdle you'll need to jump.

By following these four expert tips, however, you're sure to not only code correctly, but also bring in every dollar your urologist deserves for circumcision services.

1. Choose Code Based on Method, Patient Age

Typically, urologists don't perform newborn circumcisions, but rather adult or adolescent circumcisions. Based on the method and the patient's age, CPT offers you three codes for circumcisions:

• For a surgical "clamp" circumcision, report 54150 (Circumcision, using clamp or other device with regional dorsal penile or ring block), says

Chandra L. Hines, business office manager for N.C.  rological Associates Inc. in Raleigh. You should expect to see this type of circumcision performed on newborn infants.

• For a formal surgical circumcision in a patient who is 28 days of age or younger, you should assign 54160 (Circumcision, surgical excision other than clamp, device, or dorsal slit; neonate [28 days of age or less]).

• Report surgical circumcision of males older than 28 days of age (including adults) with 54161 (Circumcision, surgical excision other than clamp, device or dorsal slit; older than 28 days of age).

Quick work: If your urologist never performs an infant circumcision (either a clamp or formal circumcision), he or she needs to know only 54161 for an adult or adolescent circumcision.

2. Employ Modifier 52 in Some Cases

When your urologist performs a "clamp" circumcision without a dorsal penile or ring block, you should attach modifier 52 (Reduced services). In 2007, the AMA changed the 54150 code descriptor to include the nerve block and offered guidance on how to code when your urologist doesn't perform the entire procedure described. "According to CPT Changes 2007 you do need to report 54150 with a 52 modifier when it is performed without dorsal penile or ring block," says Alice Kater, CPC, PCS, coder for Urology Associates of South Bend, Ind.

Keep in mind, however, that only 54150 includes the  anesthesia (64450, Injection, anesthetic agent; other peripheral nerve or branch). Therefore, for some (but not all) non-Medicare payers you  can report 64450 along with 54160 or 54161 if your urologist performs a surgical circumcision with a nerve block. Some Medicare carriers and some commercial payers include local anesthesia in the surgical procedure and you cannot separately bill 64450. Check with your payers for further information on billing for local anesthesia administered by the surgeon involved.

3. Bill Patient for Non-Medically Necessary Circs

When your urologist performs a circumcision, your payer may not reimburse you if there is no medical reason for the procedure. Most payers do not consider circumcisions requested by a patient  for cosmetic or religious reasons to be medically necessary, and, therefore, they will not pay you for the procedure.

"We would never be paid for a cosmetic circumcision," Kater says. On the other hand, "we never have a problem getting paid by any payer for circumcisions that are medically necessary." When the circumcision is medically necessary, you must use the appropriate diagnosis code to ensure reimbursement. Two typical diagnoses that payers reimburse as medically necessary are phimosis (605, Redundant prepuce and phimosis) and balanitis (607.1, Disorders of penis: Balanoposthitis, balanitis), Hines points out.

Phimosis is a condition of the penis in which the prepuce can't be drawn back to uncover the glans penis. Balanitis, also known as balanoposthitis, is commonly described as an infection of the foreskin. Urologists often perform circumcisions to treat these conditions, and payers will reimburse for these procedures with the correct diagnostic codes.

Don't miss: Covered diagnosis codes may vary from payer to payer, so if your urologist performs a circumcision for a diagnosis not represented by one of the above codes, don't assume the surgery isn't covered. Again, check your payer's policy.

Tip: Your payer may require preauthorization even for medically necessary circumcisions. For example, "we do have a couple of Medicaids which require prior authorization for these now," Kater explains. Check with your payers about their coverage and policies regarding circumcisions.

Remember: If the patient wants a circumcision and you know your payer will not cover the procedure, ask the patient to sign a waiver or an advance beneficiary notice to inform him that he may be responsible for payment. For adult or pediatric circumcision performed for cosmetic or religious reasons, link diagnosis code V50.2 (Routine or ritual circumcision) to the circumcision code.

4. Carefully Calculate Counseling Time

Typically, before your urologist performs a circumcision he will provide some sort of E/M service or counseling concerning the procedure. "Circumcision counseling is pretty straightforward and usually only warrants a level two or three encounter," Kater says.

Exception: Circumcision counseling sometimes can take a long time, especially if the patient has questions and is trying to make up his mind about having the procedure. If more than 50 percent of the encounter is spent on counseling, you may be able to select the E/M level based on time, which can result in a higher level service, Hines says.